Healthcare Provider Details

I. General information

NPI: 1184019986
Provider Name (Legal Business Name): CASEY MCROY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2015
Last Update Date: 07/12/2021
Certification Date: 07/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 E BANNOCK ST
BOISE ID
83712-6241
US

IV. Provider business mailing address

PO BOX 1108
CORVALLIS OR
97339-1108
US

V. Phone/Fax

Practice location:
  • Phone: 208-381-2094
  • Fax: 208-381-1791
Mailing address:
  • Phone: 805-286-3826
  • Fax: 805-221-6843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number72633-20
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberM-15712
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: